Provider Demographics
NPI:1801961834
Name:BODLAK, BOHDAN E (MD)
Entity type:Individual
Prefix:
First Name:BOHDAN
Middle Name:E
Last Name:BODLAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:209 NE 95TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2745
Mailing Address - Country:US
Mailing Address - Phone:305-836-8410
Mailing Address - Fax:305-836-9727
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-2063
Practice Address - Country:US
Practice Address - Phone:305-836-8410
Practice Address - Fax:305-836-9727
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2015-10-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME53356208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3592OtherNHP
FL048766000Medicaid
FL112105AOtherHUMANA
FL07671OtherBLUE CROSS BLUE SHIELD
FL0969598001OtherCIGNA
FL0969598001OtherCIGNA